VSD

What is the embryology of VSD?

The interventricular septum consists of two parts muscular
and membranous septa. The muscular interventricular septa
develops as an outgrowth from the floor of the primitive
ventricle and grows toward the endocardial bar. Growth of the
septum ceases when it reaches the endocardial bar leaving an
aperture, that is the interventricular foramen. The floor of this
opening is formed by the endocardial bar. This opening will be
closed by the membranous septum which develops as an
outgrowth from the endocardial bar and the endocardial
ridges. Isolated VSD may result from faulty growth of the right
sided cushions. The common form of interventricular septal
defect is due to maldevelopment of the membranous septum
which results in high or membranous VSD. The defect is less
commonly situated in muscular septum called muscular VSD,

How will you classify VSD?

Based on number

Single VSD
Multiple (Swiss Cheese type) VSD

According to size

Small VSD <0.5 cm2/m2

Moderate VSD 0.5 to 1 cm2/m2
Large VSD > 1 cm2/m2

According to site

Supracristal
Infracristal

According to flow

Restrictive VSD
Non restrictive VSD

What is swiss chess type VSD?

VSD associated with multiple fenestrations in the ventricular

septum.

Syndromes associated with VSD?

o Chromosomal anomalies - downs, Edwards, Pataus, cri du
chat, deletion 4p, penta X, 10q-,13q-,18q-, triploidy, trisomy 9
o Syndromes cornelia de lange, klippel-feil, cardiofacial, fetal
alchol, CHARGE, Fetal hydantoin, Alperts, Ellis-van Creveld,
Rubinstein Taybi, Meckel Gruber, Smith-Lemli-Opitz,
Treacher Collins syndrome, Velocardiofacial syndrome,
VATER syndrome, Crouzons syndrome, Holt-Oram Syndrome.
o Maternal conditions GDM, Phenyketonuria
o Tetratogenic agents Alcohol, Hyantoin, Valproate,
Trimethadone

Clinical features of small VSD?

o Inspection and palpation normal
o Ausculation S2 is normal, loud pansystolic murmur along the
left sternal border with / without thrill.

Clinical findings of moderate VSD

o Pulse normal or brisk
o Moderate parasternal lift
o S1 loud at apes due to increased left ventricular end diastolic
volume and workload.
o S2 is often widely split with normal or slight increase in
intensity of p2
o Loud p2 due to increased pulmonary blood flow.
o Occasionally S3 may be heard.
o Murmur Grade 4 6 , loud, harsh, holosystolic murmur,
associated with thrill best heard along left sternal border.
o Soft, short systolic murmur in the second left ICS (due to PHT)
o A MDM in mitral area due to increased blood flow across mitral
valve.
o EDM due to pulmonary regurgitation.

Clinical features of large VSD

o S2 is loud and closely split with loud P2
o Loud psm with thrill at left lower sternal border.
o S3 will be heard
o Mid diastolic rumble

o Murmur in upper left parasternal area due to ejection of blood

into the pulmonary artery or mild functional infundibular
stenosis.
o Pulmonary ESM may be preceeded by an ejection click.
o EDM

Natural history of VSD

o Spontaneous closure in VSD occurs frequently in small defects
and more often in the first year of life. Large defects tend to
become smaller with age
o Some infants with large VSD may develop infundibular
stenosis resulting in decreased left to right shunt. It may even
produce right to left shunt in some cases
o CCF develops in infants with large VSD.
o Pulmonary vascular obstructive disease may develop as early
as 6 12 months of age in patients with untreated large VSD,
but right to left shunt usually does not develop until second
decade of life.

Which type of VSD closes spontaneously?

When defect is perimembranous or in the muscular septum
and size is small (diameter <0.5 cm2/m2 BSA). Infundibular types
does not close spontaneously.

Indications for surgical closure of VSD?

Development of pulmonary hypertension
Pulmonary to systemic flow rate is >1.5:1
CCF not responding to medical treatment
Infective endocarditis
Large VSD
When associated with other cardiac defects

Complications of surgical closure?

Conduction blocks
Residual VSD
Higher surgical risks for swiss cheese type VSD